Against Medical Advice Discharges: Pediatric Considerations

Abstract

Discharges against medical advice are a common phenomenon accounting for 1–2% of discharges of general medical inpatients in the United States and Canada. They are more common in certain patient populations, but targeted interventions have been limited. Many institutional policies focus on conveying the potential risks of discharge and documenting that patients understand them. Focusing on the medical risks unfortunately ignores the varied reasons patients have for requesting discharge, including family obligations and financial concerns. Principled negotiation is a potential strategy to address requests for discharge that providers consider premature. This negotiation method seeks to develop wise outcomes efficiently by explicitly addressing the relationship, focusing on the underlying interests, considering a wide range of options, and seeking objective criteria. Providers of adult patients have an obligation to assure that patients discharged against medical advice possess medical decision-making capacity and do not fulfill the criteria for civil commitment. In addition, providers of pediatric patients should assure that discharge does not constitute medical neglect, i.e., patients are not at imminent risk of serious, preventable harm. If an agreement cannot be reached, providers should still assure that an adequate discharge plan is in place. Having patients sign the discharge plan may encourage their adherence.